Strategic Objective 3.3: Support strong families and healthy marriage, and prepare children and youth for healthy, productive lives

Strategic Objective 3.4: Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers

Poverty, unemployment, family disruptions, aging, and disability can threaten independence and self-sufficiency and increase Americans’ need for safety-net programs. Violence and preventable injuries threaten the security and social stability of the American people. HHS is committed to supporting the social and economic well-being of all Americans, including those individuals and populations who are at high risk of social and economic challenges. A core component of the HHS mission is the dedication to serve all Americans from conception to natural death, including those individuals and families who face or who are at high risk of economic and social well-being challenges.

According to the U.S. Census Bureau, the official poverty rate in 2016 was 12.7 percent, down 0.8 percentage points from 13.5 percent in 2015. Both the percentage of the U.S. population in poverty and the unemployment rate have declined in the last three years. According to the U.S. Department of Labor’s Bureau of Labor Statistics, in 2017 the monthly unemployment rate averaged 4.4 percent, down from 4.9 percent in 2016.

However, some Americans still experience challenges. According to the 2016 Annual Homeless Assessment Report, on a single night in 2016, nearly 550,000 people were experiencing homelessness in the United States. Additionally, in 2011, 4.8 million formerly incarcerated individuals were under community supervision. Many individuals returning to the community after serving time experience challenges due to limitations on their eligibility for access to public housing, employment, and healthcare. Job training and social supports are imperative for ensuring that these individuals are able to reintegrate into their communities.

Both unintentional injuries and those caused by acts of violence are among the top 15 causes of death for Americans. Nearly 200,000 people in the United States die every year from injuries and violence related to preventable events such as drug overdoses, falls, drowning, and self-harm. Even when people do not die from injuries and violence, many experience long-term effects. Survivors often face lifelong mental, physical, and financial problems. In 2014, 26.9 million people were treated in an emergency department for injuries, and 2.5 million people were hospitalized. In 2013, costs associated with fatal injuries totaled $214 billion, while nonfatal injuries resulted in $457 billion in costs.

The Department’s effort to support all Americans includes empowering families to encourage positive child and youth development. Financial and emotional support can encourage children and youth to continue education and make healthier decisions. In 2010, 71 percent of children younger than 18 were reported to be living with at least one parent who was employed full-time, year round. In 2014, 79.3 percent of adolescents age 12 to 17 surveyed said they had an adult in their lives with whom they can discuss serious problems, up from 78.2 percent in 2013.

Over the past 15 years, there has been significant improvement in the teen birth rate. The teen birth rate declined by 63 percent between 1990 and 2015 and is now at a record low. In 1990, the teen birth rate was 60 births per 1,000 teenage girls. By 2015, the rate had dropped to 22 births per 1,000 teenage girls.

Some subpopulations are at high risk of poor economic and social outcomes. In 2015, 35 percent of single-parent families had incomes below the poverty line, compared with 8 percent of married couples with children. Over the past decade, the percentage of children in single-parent families has increased from 32 percent to 35 percent, although the percentage has remained stable since 2011. Additionally, the more than 400,000 children who live in foster homes face a complex set of challenges. Older foster youth who age out of foster care are at a higher risk of teen pregnancy, employment instability, and homelessness.

Older Americans and Americans with disabilities also face a number of obstacles. Over the past 10 years, the population 65 and over increased by 30 percent from 36.6 million in 2005 to 47.8 million in 2015, and this age group is projected to more than double to 98 million in 2060. More than 4.2 million older adults lived below the poverty line in 2015. At least 90 percent of older adults receiving help with daily activities receive some form of unpaid care, and about two-thirds receive only unpaid care. Almost 12 percent of working-age adults in the United States have some type of disability. Of these adults, 51 percent had a mobility disability, and 38.3 percent had a cognitive disability. Working-age adults with disabilities are more likely to live in poverty, have less than a high school education, and be unemployed.

Within HHS, the following divisions are working to achieve this goal: Administration for Children and Families (ACF), Administration for Community Living (ACL), Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration (HRSA), Indian Health Service (IHS), Office of the Assistant Secretary for Health (OASH), and Substance Abuse and Mental Health Services Administration (SAMHSA).

Strong, economically stable individuals, families, and communities are integral components of a strong America. Many Americans currently experience or are at risk for economic and social instability. The social and health impacts of poverty can include reduced access to nutritious food; fewer educational opportunities and poor educational outcomes; a lack of access to safe and stable housing; increased risk of poor health outcomes including obesity and heart disease; and difficulty obtaining work opportunities.

In 2016, a family of three was considered to be living in poverty if they earn less than $19,105 per year. According to the Census Bureau, the poverty rate in 2016 was 12.7 percent, with 40.6 million people living in poverty; this number was down 0.8 percentage points from 2015. For most demographic groups, the number of people in poverty decreased from 2015, with adults older than 65 the only population group experiencing an increase in the number of people living in poverty. By providing opportunities for work and work supports, the Department is dedicated to improving the education, skills, health, and resources of low-income individuals and families to help them expand their productivity, achieve economic independence, and enhance their economic and health outcomes.

To reach this goal, the Department coordinates safety-net programs across the Federal Government; State, local, Tribal, and territorial governments; and faith-based and community organizations. One of the Department’s primary programs for families in need is the Temporary Assistance for Needy Families (TANF) program. TANF provides States with block grants to design and operate programs that help needy families reach self-sufficiency, with a focus on preparing parents for work. The Department coordinates with the U.S. Departments of Labor and Education to implement the Workforce Innovation and Opportunity Act, which is designed to help young job seekers and people with disabilities access employment education, training, and support services and match employers with skilled workers.

Contributing Operating Divisions and Staff Divisions

ACF, ACL, and CMS

Strategies

In March 2017, nearly 2.5 million people across all 50 States, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands received cash assistance from TANF programs. The Department invests in education, training, work, and work supports through the following strategies:

Strengthen the required work participation rate standards for States receiving TANF funds, and provide guidance and technical assistance to State TANF programs to engage adult cash assistance recipients who have the capacity to work in work activities

Promote innovation in the TANF program to advance the objective of helping families in need find stability and support through the employment and economic independence of adult participants and the healthy development of children whose families receive assistance

Integrate refugees entering the country into American society and connect them with wraparound services and resources, using faith-based and community organizations, to provide economic opportunity and success

Provide assistive technology equipment to people with disabilities, allowing them more self-sufficiency and eliminating barriers to their economic opportunity

Increase the number of employed people with disabilities by encouraging and assisting integration into the greater community’s workforce

Note: Additional strategies on supporting independence for people with disabilities are in Strategic Objective 3.4.

Although the number of people in poverty is shrinking, in 2016, 40.6 million people lived below the poverty line, with 32 percent of these people under the age of 18. The Department is working to reform human services programs to assist low-income populations through the following strategies:

Foster coordination and innovation across safety-net programs, including faith-based and community organizations, to help individuals and families in need to become self-sufficient and end dependency through employment and growth in habits of personal responsibility

Increase access to comprehensive services as part of short-term, transitional public welfare services in partnership with other Federal agencies and faith-based and community organizations, including programs to promote social and economic self-sufficiency for American Indians and Alaska Natives

Support formerly incarcerated individuals in obtaining and maintaining employment, developing habits of personal responsibility, reconnecting with their children and families, paying child support, and avoiding recidivism

Become a center of excellence in the research and practice of facilitating rapid and sustained economic independence for diverse at-risk populations

The Department participates in the U.S. Interagency Council on Homelessness, which coordinates the Federal response to homelessness by partnering with 19 Federal agencies, State and local governments, advocates, service providers, and people experiencing homelessness, with a goal of ending all homelessness in America. The Department is working with its partners to reduce the incidence of homelessness through the following strategies:

Strategic Objective 3.2: Safeguard the public against preventable injuries and violence or their results

Injuries and violence affect all Americans regardless of an individual’s age, race, or economic status. Preventable injuries and violence—such as falls, homicide stemming from domestic violence, and gang violence—kill more Americans ages 1 to 44 than any other cause, including cancer, HIV, or the flu. Hospitalizations, emergency room visits, and lost productivity caused by injuries and violence cost Americans billions of dollars annually.

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. The Department supports multiple trauma-informed care initiatives to integrate a trauma-informed approach into health, behavioral health, and related systems, to reduce the harmful effects of trauma and violence on individuals, families, and communities.

In 2015, the age-adjusted rate of unintentional injuries (43.2 per 100,000) increased 6.7 percent from the rate in 2014. The largest subcomponent of injury mortality is poisoning, with a rate 1.5 times greater than that of motor vehicle traffic deaths. In 2015, the age-adjusted rate of drug overdose deaths was more than 2.5 times the rate in 1999. The pattern of drugs involved in drug overdose deaths also has changed in recent years. In 2010, 29 percent of drug overdose deaths involved natural and semisynthetic opioids, and 12 percent involved methadone. In 2015, the percentage of drug overdose deaths involving these drugs decreased to 24 percent and 6 percent, respectively. In contrast, drug overdose deaths involving heroin increased from 8 percent in 2010 to 25 percent in 2015. Increases also were seen in drug overdose deaths involving synthetic opioids other than methadone, from 8 percent in 2010 to 18 percent in 2015.

Contributing Operating Divisions and Staff Divisions

ACF, ACL, CDC, IHS, OASH, and SAMHSA

Strategies

HHS funds 23 State health departments through the Core State Violence and Injury Prevention Program (Core SVIPP), which helps States implement, evaluate, and disseminate strategies that address the most pressing injury and violence issues, including child abuse and neglect, traumatic brain injury, domestic violence, and sexual violence. Core SVIPP aims to decrease injury- and violence-related morbidity and mortality and increase sustainability of injury prevention programs and practices. The Department also is working to identify and disseminate evidence-based practices to reduce injuries and violence through the following strategies:

Expand knowledge about important abuse intervention models to enhance evidence-based services for older adults and adults with disabilities

Ensure more children safely avoid foster care placement by encouraging the availability of effective, accessible family support services to address the issues families face, including the opioid crisis

Homicide is the third leading cause of death for young people ages 15 to 24, with more than 4,000 young people dying by homicide each year. One in four women, and one in nine men, were victims of sexual violence, physical violence, or stalking by an intimate partner, resulting in injury, fear, and a concern for their safety. The Department funds services to support those who have been impacted by injuries and violence, including through the following strategies:

Note: Additional strategies to support older adults are in Strategic Objective 3.4.

The Department works across the Federal Government, and with States, territories, Tribes, and faith-based and community organizations, to address injuries and violence—monitoring accidental and violence-related injuries, supporting research on the factors that put people at risk, creating and evaluating preventative programs, helping partners plan and implement programs, and conducting research on the effective adoption and dissemination of these strategies. The Department is working to expand partnerships with Federal, State, Tribal, local, and territorial government entities and other stakeholders to reduce injuries and violence through the following strategies:

Protect women from harmful exposures before, during, and after pregnancy, such as from domestic violence, tobacco exposure, and alcohol, opioid, and other harmful substance use, and improve outcomes for newborns and pregnant women

Expand interagency partnerships and systems to train healthcare and human service providers to assess for domestic and dating violence and do brief interventions to link victims to safety and support services, including through faith-based and community organizations

Expand and strengthen partnerships with Federal, State, local, Tribal, and territorial partners, including faith-based and community organizations, on gang prevention programs as well as investing in youth mentoring and coaching, counseling, and life skills and workforce training

Assess and increase the capacity of medical and behavioral health practitioners, nonprofits, faith-based and community organizations, licensed social workers, child welfare professionals, housing authorities, and public health agencies to provide comprehensive and survivor-informed services for victims of human trafficking

Improve services to children and families in the child welfare system as a result of parental or caretaker opioid or other substance use disorder, including through faith-based and community organizations

Enhance the cultural competence of the workforce in the delivery of social services to children, youth, and families through research, technical assistance, and training

Nearly 192,000 people die from violence and injuries each year—nearly 1 person every 3 minutes. The Department is working to collect, analyze, and report national data on the incidence and consequences of injuries and violence through the following strategies:

Assess healthcare use and costs associated with violence and unintentional injury, including patient safety events that occur in healthcare settings, to inform actions to prevent injury and violence and describe the return on investment of public health action

Develop and enhance timely, coordinated data systems to monitor injuries and violence by using expanded surveillance, innovative methods, and new technology, to inform and evaluate national and State prevention activities

Address gaps in data on prevalence and risk factors for child maltreatment

Strategic Objective 3.3: Support strong families and healthy marriage, and prepare children and youth for healthy, productive lives

Families are the cornerstone of America’s social fabric. A strong family can lead to many positive outcomes for the health, social, and economic status of both adults and children. People live longer, have less stress, and are more financially stable in a healthy family environment where both parents are present, share the responsibility of the household, and raise the children. Additionally, in these households, children tend to be healthier, both mentally and physically, and are better able to have their fundamental needs met.

The Department supports healthy families and youth development through collaborations across the Federal Government and with States, territories, community partners, Tribal governments, and faith-based organizations. Head Start served 1.1 million children from birth to age 5 and pregnant women in 2015–2016, and approximately 1.4 million children per month received child care assistance in 2015. Recommendations for best practices for early child development are shared with partners across the country. Transitions from youth to adulthood are supported through the promotion of strength-based approaches, multisector engagement, and youth engagement efforts.

Through programs like the Healthy Marriage and Relationship Education Grant Program, the Department funds organizations (including faith-based and community organizations) across the country to provide comprehensive healthy relationship and marriage education services, as well as job and career advancement activities to promote economic stability and overall improved family well-being.

Children with involved fathers are more likely to perform well in school, have healthy self-esteem, and display empathy and pro-social behavior, compared with children who have uninvolved fathers. The New Pathways for Fathers and Families funds organizations across the United States to provide responsible-fatherhood activities that strengthen positive father-child engagement, improve employment and economic mobility, and improve relationships (including couple and coparenting) and marriage. The Department also supports reentry efforts for incarcerated fathers. Approximately 1.7 million State and Federal inmates are fathers of minor children. The impacts of incarceration affect the lives and well-being of their children and families. The Responsible Fatherhood Opportunities for Reentry and Mobility program funds grants that are specifically tailored to the needs of fathers transitioning from incarceration to their families and communities. Grants help fathers stabilize their lives, establish or reconnect with their children and families, develop habits of personal responsibility, obtain employment, and achieve economic mobility.

Contributing Operating Divisions and Staff Divisions

ACF, ACL, CDC, HRSA, IHS, OASH, and SAMHSA

Strategies

In 2016, the United States was home to 73.6 million children, a number that is projected to grow to 74.5 million by 2022 and 76 million by 2029. The Department supports the healthy development and well-being of children through the following strategies:

Improve the quality of care and education settings through effective professional development, coaching, monitoring for health and safety, provision of comprehensive services, and other training and technical assistance in order to promote positive teacher-child interactions and support children’s skill development in all domains, including language, early literacy, numeracy, cognitive, and social-emotional development

To achieve optimal brain development for all children, identify and promote effective approaches for early language development to integrate them into existing programs that reach young children, and leverage partnerships (including with faith-based and community organizations) to encourage broad implementation

Promote increased physical activity and active play, improved nutrition, reduced screen time, and increased interpersonal contact with and between children in child care and early childhood development programs

Improve access to high-quality early care and education opportunities for young children by improving the quality of existing early care and education settings, including those offered by Tribes and faith-based and community initiatives, and building the supply of high-quality options for families

Reduce barriers to child and family participation in early childhood programs and services

Provide effective training and technical assistance to help parents and families have greater involvement with teachers, educators, and caregivers to improve the quality of early childhood settings

Through the Interagency Working Group on Youth Programs, the Department collaborates with other Federal departments and agencies to support at-risk youth through adolescence and young adulthood. The Department supports the healthy development and well-being of adolescents and young adults through the following strategies:

Support successful youth transitions to adulthood by strengthening relationship and employability skills and the development of habits of personal responsibility

Invest in training to support adults in detecting and responding to mental illness in children and youth, including encouraging adolescents and their families to seek treatment

Prevent and reduce morbidity, mortality, and key risk behaviors among youth by supporting schools and communities to improve youth skills through sound health education and connection to needed services, and promoting school environments that protect and nurture youth to avoid risk and make positive life choices

Support efforts to place children in foster care with extended birth family and support these kinship caregivers

Promote efforts to recruit, train, and support adoptive families for children and youth whose birth parents and relatives cannot or will not safely care for them

Support efforts to ensure the well-being of children in foster care and those who age out of foster care without a family

While most children live with two parents, the Census Bureau estimates that 23 million children live in households with only one parent or no parent at all. The Department supports parents, guardians, and caregivers through the following strategies:

Improve opportunities for parent participation in an evidence-based parenting curriculum or mentoring programs to improve parenting skills and lead to better learning and development outcomes for children and marital and family stability

Support and engage fathers in innovative program models across agencies to better integrate them into their families’ life

Support families with young children by addressing parental mental health or substance abuse

Develop and implement local and national dissemination strategies to communicate the value of healthy marriages and relationships, and of the success sequence, which recommends completing education, obtaining employment, and getting married before a first or subsequent child, across all socioeconomic demographics

The Department recognizes that other risk factors like poverty, food insecurity, and housing instability can negatively impact health, and is working to integrate human services and health supports to support the well-being of children, youth, and families through the following strategies:

Ensure more young children become up to date on all age-appropriate preventive and primary healthcare, including sensory and developmental screening, with appropriate referral and intervention

Promote interagency Federal, State, and local coordination, including through Tribes and faith-based and community organizations, to facilitate families’ access to services and help them navigate systems of care across the full spectrum of family needs, including housing, education and training, healthcare, child care, social services, and economic supports

Integrate age- and developmentally appropriate strategies into programs designed to help all youth avoid risk and make better choices

Strategic Objective 3.4: Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers

Older adults and people with disabilities face a complex set of difficulties. About one in every seven, or 14.9 percent, of the population is an older American. Approximately 12 percent of working-age adults in the United States have some type of disability. Of these adults, 51 percent had a mobility disability, and 38.3 percent had a cognitive disability.

Older people and people with disabilities often rely on other people to fulfill fundamental needs and complete daily tasks. In order to facilitate adequate care and maximize independence, older adults and people with disabilities of all ages should be able to live where they choose, with the people they choose, and with the ability to participate fully in their communities.

To support older adults, people with disabilities, and the system of friends, family, and community members that support them, the Department collaborates across the Federal Government, with States, Tribes, and territories, and with faith-based and community organizations. Aging and Disability Resource Centers provide a gateway to a broad range of services and supports for older adults and people with disabilities. Centers for Independent Living are community-based centers that offer services to empower and enable people with disabilities to stay in their communities. Every State and territory has an Assistive Technology Act program that can help people find, try, and obtain assistive technology devices and services. Assistive technology includes resources ranging from “low tech” helping tools—like utensils with big handles—to higher-tech solutions like talking computers.

The Department also supports caregivers of older Americans and Americans living with disabilities. At least 90 percent of older adults receiving help with daily activities receive some form of unpaid care, and about two-thirds receive only unpaid care. In 2011, an estimated 18 million unpaid caregivers provided 1.3 billion hours of care on a monthly basis to Medicare beneficiaries age 65 and over.

Contributing Operating Divisions and Staff Divisions

ACF, ACL, CDC, CMS, HRSA, IHS, OASH, and SAMHSA

Strategies

Stable housing is foundational to good health and well-being. Accessible, affordable housing is essential to community integration and aging-in-place. For some older adults and people with disabilities, additional assistance is required to support community living. The Department works to strengthen supports for community living through the following strategies:

Support age- and dementia-friendly livable communities to improve quality of life for older adults, families, caregivers, people with disabilities, and the larger community

Foster culture change through inclusion and accessibility for children and adults with disabilities and older adults by removing physical and other barriers

Support programs for people with disabilities and older adults that help protect them from all forms of abuse, including physical, mental, emotional, and financial abuse, and help ensure their ability to exercise their rights to make choices, contribute to their communities, and live independently

In Olmstead v. L.C., the Supreme Court affirmed that under the Americans with Disabilities Act, people with disabilities cannot be unnecessarily segregated and must receive services in the most integrated setting appropriate for their needs. Federal and State efforts following this landmark decision have increased community participation and independence of people with disabilities and older Americans who are living in communities, including those who have transitioned from nursing homes and other institutions. The Department is working to support choice across the care continuum, as well as improved care transitions and care coordination, through the following strategies:

Promote collaboration among Federal, State, Tribal, local, territorial, and private-sector partners that serve older adults, people with disabilities, and their families and caregivers to improve access to a full range of healthcare services, and home and community-based services

Pursue initiatives and programs to provide support to older adults, people with disabilities, and their families and caregivers as individuals move between the settings that best address their unique needs

Increase the proportion of youth with disabilities who have plans in place for transitioning from pediatric to adult care

Approximately 20 percent of older Americans receive assistance with their care needs. Medicaid is the largest source of support for long-term services and supports, with an estimated $131.4 billion annually expended at the Federal and State levels. The Department is working to improve quality and availability of long-term services and supports, including home and community-based services (HCBS), through the following strategies:

Support the development of a core set of performance measures for HCBS that can provide data that can be used in quality and outcome measurement and reporting

Support innovative delivery system models and program flexibilities that include HCBS to improve quality, accessibility, and affordability in Medicare and Medicaid

Consider new person-centered models of care in Medicare and Medicaid that provide an integrated approach to addressing individuals’ medical, behavioral, long-term services and supports, and other needs to maintain health, well-being, and independence

Identify opportunities to accelerate the development, evaluation, translation, implementation, and scaling up of comprehensive care, services, and supports for persons with dementia, families, and other caregivers

Assist States in strengthening and developing high-performing long-term services and supports systems that focus on the person, provide streamlined access, and empower individuals to participate in community living

Alzheimer’s disease (AD) is an irreversible, progressive brain disease that affects as many as 5.3 million Americans. The prevalence of people with AD doubles for every 5-year interval beyond age 65. Without a preventive treatment or cure, the significant growth in the population over age 85 that is estimated to occur between 2015 and 2050 (from 6.3 million to 19 million) suggests a substantial increase in the number of people with AD. The Department is working to address Alzheimer’s disease and related dementias through the following strategies:

Improve data to track the burden of Alzheimer’s disease and related dementias, identify and monitor trends in associated risk factors, and assist with understanding health disparities

Note: Additional strategies on preventive care are in Strategic Objectives 1.3 and 4.3.

Caregivers provide care to people of all ages who live in residential or institutional settings. Caregiving can be both paid and unpaid; a 2009 survey found that approximately 25 percent of adults reported providing care to a person with a long-term illness or disability in the past 30 days. The Department is working to strengthen supports for caregivers through the following strategies:

Provide support for unpaid family caregivers, to maximize the health and well-being of the caregivers and the people for whom they provide care

Educate and empower community supports, such as faith-based and community organizations, for providing support of all types for caregivers

Identify research gaps in caregiving, and optimize sharing of research findings

For people with complex health needs, such as older adults and people with disabilities, accessing high-quality and affordable care—healthcare, as well as assistance for daily living—can be challenging. Geographic disparities, as well as economic constraints, can limit the number and quality of available options. The Department is working to reduce disparities in services for older adults and people with disabilities through the following strategies:

Include culturally appropriate, person- and family-centered care planning in Federal social and healthcare services for older adults and persons with disabilities to protect individual choice and address a person’s current and future economic resources, including advance care planning needs

Monitor, using existing data sources, the status of the health, well-being, and independence of older adults and people with disabilities, and improve reporting on these populations

The number of people 65 years old and older is expected to double between 2000 and 2030. Providing high-quality services to this growing population requires a high-quality workforce. The Department seeks to strengthen the workforce through the following strategies:

Educate the healthcare and service professional workforce on the concerns of a geriatric population to ensure awareness of the unique challenges and issues of older adults

Improve and increase competency in the healthcare and direct service workforce in person-centered approaches and cultural competency

Strengthen the training and capacity of healthcare providers to recognize, assess, refer, connect, and engage caregivers

Strengthen partnerships between academia, health delivery systems, Tribes, and faith-based and community organizations to educate and train the workforce to provide high-quality, culturally competent care

As a result of the Protection and Advocacy Program’s individual or systemic advocacy, the percentage of individuals with developmental disabilities whose right to be safe, receive an appropriate education, live in the community, be economically self-sufficient, and/or participate in their communities is enforced, retained, restored, or expanded